BACKGROUND
Bariatric surgeries are a medical option for individuals with clinically severe obesity with predetermined body mass index (BMI) values (BMI ≥40 kg/m2 without comorbidities or a BMI ≥35 kg/m2 with comorbidities) to help facilitate weight loss (5). Approximately, one-third of U.S. adults are obese, whereas 17% of children and adolescents 19 years of age and younger are considered obese (30). From 2009 to 2010, the prevalence of obesity in the United States was estimated to be 35.5% among adult men and 35.8% among adult women (30). Projecting forward through the next 2 decades, obesity (BMI >30 kg/m2) is expected to increase by an additional 33% and severe obesity (BMI >40 kg/m2) is projected to increase 130% (16). Furthermore, the associated medical costs for obese patients is estimated to be $1,429 higher per year than those of normal weight, resulting in a $147 billion price tag per year in the United States alone to treat obesity (17). The United States now spends over $190 billion annually on health care directly related with obesity (11). A projection provided by The American Public Health Association in 2009 showed that 43% of adults in the United States will be obese by 2018, quadrupling medical costs to an astounding $344 billion per year (40). However, if obesity rates are instead held at current levels, the United States would offset nearly $200 billion in health care costs (40). Consequently, bariatric surgery has increased in prevalence and has become an established and effective long-term treatment strategy for morbidly obese individuals (41).
Bariatric surgery is a collective term used to describe three common bariatric surgery approaches: Roux-en-Y-gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), and gastric sleeve (GS). During RYGB, a small gastric pouch is formed from the top of the stomach involving the small intestine and the two “limbs” it is separated into: the biliopancreatic limb and the Roux limb. The biliopancreatic limb, also known as the duodenum, is located at the beginning of the small intestine and subsequently receives the digestive juices from the stomach, bile, and pancreas. The Roux limb, also known as the jejunum, is the middle part of the small intestine and plays a key role in nutrient absorption. As the small pouch is formed, the duodenum (biliopancreatic limb) produces digestive juices that flow into the jejunum (Roux limb), which is reattached below the jejunum, and the jejunum gets connected to the pouch (38). This allows food to flow directly from the pouch into the jejunum, bypassing most of the stomach. Although successfully limiting the amount of food that can be ingested and improving energy expenditure rates after 6 months of weight loss (15), this surgery is sometimes complicated by malabsorption of selected vitamins and minerals (2). Common vitamin and mineral deficiencies include iron, folate, vitamin B12, calcium, zinc, protein, and all of the fat-soluble vitamins (A, D, E, and K) (2).
During LAGB, a small pouch is created by wrapping a silicone band around the upper stomach narrowing the gastric passage. The silicone band can be adjusted using saline injected into an external port to make the pathway for food larger or smaller, depending on any number of individual clinical considerations. When the LAGB is maintained appropriately, eating just a small amount of food (approximately 3 tablespoons) will satisfy hunger and help reduce overall volume of food being consumed (5).
During GS, about 85% of the stomach is removed, creating a banana-like pouch that restricts expansion of the gastric space without altering small intestine absorption. GS will limit the amount of food that can enter into the stomach and considerably impacts the quantity that can be consumed (5). With the increased prevalence of obesity, the demand for such surgical approaches has also increased, but each approach brings a number of nutritional challenges that health professionals face when interacting with bariatric clients. The purpose of this article is to highlight and discuss common nutritional challenges with the bariatric surgery population to better inform health and fitness professionals on how to safely and effectively interact with these unique clients.
NUTRITIONAL CHALLENGES OF THE BARIATRIC PATIENT
Although undergoing bariatric surgery can be an effective strategy to stimulate weight loss, a number of nutritional considerations exist that can help to promote healthy, continual weight loss. For example, nutrition assessment and frequent dietary management are needed to help ensure that caloric and macronutrient intakes are at an appropriate level to support weight loss while also identifying any risks for nutritional deficiencies that may already exist or may develop (2). Although it is important for all populations to consume a diet rich in vitamins and minerals, the bariatric population is recognized as a population to have a number of preexisting nutritional deficiencies before undergoing surgery (36).
In this respect, multiple previously published reports have highlighted poor intakes of the B-complex vitamins, iron, zinc, vitamin C, and the fat-soluble vitamins (vitamins A, D, E, and K) in patients undergoing bariatric surgery (8,18,36). To date, no clear explanation exists as to why bariatric candidates exhibit such poor dietary habits. It is likely due to habitual intake of highly processed foods that offer high energy content but low nutrient density (24). Poor dietary habits before having weight loss surgery are particularly concerning to postoperative health outcomes. Consequently, with a significantly reduced caloric intake, one has fewer opportunities to consume a balanced array of nutrients required by the body.
For these reasons, before surgery, 3–6 months of medical weight management is commonly required by insurance companies in an attempt to promote healthier habits before surgery that can be implemented after surgery. Medical weight management is often administered by a multidisciplinary team, including a physician, dietitian, and behavioral specialist, that provides the opportunity to recognize individuals at risk for nutritional deficiencies preoperatively thus avoiding the risk and cost of the surgery for those who are likely to be poorly managed after the surgery (9,24).
POSTOPERATIVE NUTRIENT DEFICIENCIES
Postoperatively, patients undergoing bariatric surgery are at an increased risk of developing nutrient deficiencies where protein, B12, folate, iron, calcium, and vitamin D are among the most commonly impacted nutrients (3). Bariatric surgery is known to alter nutritional intake through either restrictive (LAGB or GS) and/or absorption pathways (RYGB). Especially with patients undergoing RYGB, nutrient absorption is often compromised where macronutrient malabsorption rates have been reported to be 25% for protein and 72% for fat (37). This procedure also results in secondary malabsorption of micronutrients due to the restrictive nature of the procedure limiting of caloric intake. Patients undergoing RYGB are commonly low in iron, zinc, calcium, B12, thiamine, and folate, and other vitamins and minerals that rely on fat metabolism including the fat-soluble vitamins A, E, D, and K (39). In this procedure, gastric capacity is reduced by 90–95%, significantly restricting digestion and absorption (3).
Patients undergoing LAGB and using GS may also present with vitamin deficiencies in B12, folate, iron, thiamine, and calcium. In normal digestion, hydrochloric acid converts pepsinogen into pepsin which initiates the digestive process (2). Bariatric techniques including GS can significantly reduce the amount of available hydrochloric acid and may consequently limit conversion of pepsinogen to pepsin, which is necessary for protein digestion and absorption leading to the release of vitamin B12 from protein (2). Protein deficiencies often arise when daily protein intake is less than 60–80 g of protein per day and can lead to adverse symptoms such as fatigue, hair loss or thinning, edema in the extremities, and loss of lean muscle mass (12).
Additionally, folate levels are decreased making it harder to synthesize B12 properly. Having a deficiency in vitamin B12 will negatively impact red blood cell production which can lead to anemia and subsequent fatigue. In addition, iron levels are typically low postsurgery and can cause fatigue, further contributing to anemia. Iron deficiency occurs as a result of decreased absorption in the small intestine after RYGB surgery. In order for iron to be absorbed, dietary iron (ferrous iron) must be reduced to the ferrous state by the acid secretion of the stomach (3). Because there is a reduced production of hydrochloric acid after restrictive procedures, iron is less available to be absorbed (3), a situation further complicated by the surgical bypass of the duodenum and proximal jejunum, two main areas of iron absorption. In this respect, low levels of hemoglobin, iron, and ferritin were found in more than 44% of patients undergoing bariatric surgery, and vitamin B12 deficiency was found in about one-third of patients undergoing bariatric surgery after four years of RYBG (10). It has been estimated that after one year postsurgery, one-third of patients develop anemia and fat-soluble vitamin deficiencies (10). Moreover, normal calcium metabolism is restricted by means of malabsorption of fat and fat-soluble vitamins (A, D, E, and K) which can lead to bone loss.
Calcium absorption occurs primarily in the duodenum and proximal jejunum. An acidic environment facilitates absorption along with the presence of vitamin D (2). Therefore, when vitamin D levels are low, there is an associated reduction in the bioavailability of calcium (2). Consequently, the lack of calcium stimulates the production of parathyroid hormone. Secondary hyperparathyroidism triggers the conversion of 7-dehydroxycholecalciferol into the active form of vitamin D, 1,25-dihydroxycholecalciferol to stimulate the intestine to increase absorption of calcium (2). When dietary calcium is not present or intestinal permeability is impaired due to vitamin D deficiency, calcium homeostasis upregulates bone resorption (2).
The bypass of the duodenum increases the risk of developing hyperparathyroidism which can be related to reduction of calcium (21). By circumventing the duodenum, patients undergoing RYGB often see a similar trend in vitamin D deficiency and secondary hyperparathyroidism (23). The long-term effects of vitamin D and calcium deficits may cause secondary hyperparathyroidism that could ultimately result in other bone-related disorders such as osteopenia, osteoporosis, and osteomalacia (20). Calcium citrate is recommended due to its 22–27% greater bioavailability when compared to calcium carbonate regardless if taken with food (35). It is suggested that calcium citrate be recommended by the bariatric team since calcium from carbonate has no bioavailability in the absence of stomach acid (3). Although the malabsorptive nature of some surgical procedures oftentimes initiates the concern for nutrient deficiencies, practitioners should also consider the restrictive nature of caloric content and food intolerances limiting intake (26).
GASTROINTESTINAL SIDE EFFECTS
Malabsorption and nutrient deficiencies are not the only challenges faced in patients undergoing bariatric surgery. Gastrointestinal side effects are very common postoperatively and are difficult to overcome. Gastrointestinal side effects include bloating, food intolerances, lactose intolerance, vomiting, diarrhea, abdominal pain, gastro-esophageal reflux, and ulcers. Additionally, dumping syndrome is a side effect that can develop after surgery and is thought to be caused by poor dietary choices such as ingestion of refined sugars, high glycemic carbohydrates, high consumption of fats, and fried foods (4). These foods rapidly empty from the gastric pouch into the small intestine which expands too quickly due to the presence of hyperosmolar contents from the stomach. This causes symptoms due to the fluid shift into the gut lumen with plasma volume contraction and acute intestinal distention (13). Increased loading into the small intestine with hypertonic stomach contents can lead to rapid entry of water into the intestinal lumen causing osmotic diarrhea, cramping, and hypovolemia (13).
Dumping syndrome can happen in two forms: early dumping and late dumping. Dumping starting approximately 30–60 minutes after eating is considered early dumping and can last up to 60 minutes. This occurs as a result of rapid emptying of refined sugars from the gastric pouch into the small intestine which triggers hormones that effect blood pressure, heart rate, skin, and intestinal transit time. This often leads to diarrhea and causes light headedness and skin flushing (4). Dumping starting approximately 1–3 hours after eating is considered late dumping which is caused by an increased insulin surge after oral glucose followed by subsequent hypoglycemia (4). Symptoms of late dumping syndrome include: flushing, sweating, feelings of fainting, shakiness, heart palpitations, hunger, nausea, diarrhea, and cramping. Dumping syndrome is an opportunity for the bariatric team to educate the patient on proper nutrition and foods to limit these symptoms. Ingestion of these foods and its subsequent impact often causes the patient to limit or stop consuming foods that are not tolerated. About 85% of patients undergoing bariatric surgery will experience dumping syndrome at some point after surgery, thus the education on how to prevent dumping syndrome is vital during preoperative patient education (4).
WEIGHT LOSS MANAGEMENT
Bariatric surgery is very rewarding in a sense that weight loss will happen. According to meta-analysis, bariatric surgery results in substantial weight loss, where percentage of excess body weight loss averages 72.3, 33.39, and 69.7% for RYGB, LAGB, and GS, respectively, one year after surgery (6). Postoperatively, the real challenge is the management and continuation of weight loss knowing that malabsorption and nutritional deficiencies may likely occur. Mentally and psychologically, it is important to prepare patients undergoing bariatric surgery for hurdles that may occur such as not following the proper nutrition program given to them, not drinking the right amount of water, or not exercising. Adequate water consumption is crucial due to the risk of dehydration from inadequate fluid intake, vomiting, and diarrhea. Water must be consumed in small amounts throughout the day due to the size of the stomach pouch. However, patients require a minimum of 48–64 ounces of water per day (32). Furthermore, patients undergoing bariatric surgery are recommended to avoid high-sugar foods and beverages to avoid the dumping syndrome effects which induce dehydration further.
Slow incorporation of regular exercise is recommended both preoperatively and postoperatively. According to a position statement by the American Society for Metabolic and Bariatric Surgery, postoperative exercise is absolutely imperative and may be the most important factor to promote sustained weight loss (4). An exercise program (discussed in the patient undergoing bariatric support and exercise considerations) can help promote fat loss, minimize losses of lean mass, bolster the immune system, improve balance, and promote self-confidence while also reducing fatigue and even feelings of hunger (4).
Plateauing of weight loss is commonly reported at about 18 months after surgery for RYGB and GS, whereas weight loss for LAGB can last up to 36 months, averaging 5–10 lbs per month (27). Consequently, it is not uncommon for patients to question why their weight loss has stalled and wonder if they are doing something wrong or if the operation is not functioning properly (4). Patients undergoing LAGB typically see progressive weight loss through 36 months and plateauing of weight might be due to a loosening of the band. In these instances, the patient's surgeon should be notified. These questions and concerns are expected as postoperative energy balance should be tilted strongly toward a negative energy state. Although it is likely this outcome is a combination of physiological, nutritional, and psychological factors, a complete understanding of the mechanisms involved are unknown. Regardless of the mechanism, the stalling of weight loss is emotionally troubling for a patient undergoing bariatric surgery. Consequently, exercise and nutritional professionals must be prepared for these responses and the questions and concerns that are likely to come as a result from a client undergoing bariatric surgery.
NUTRITIONAL STRATEGIES OF THE PATIENT UNDERGOING BARIATRIC SURGERY
Proper nutritional assessments and dietary management in patients undergoing bariatric surgery have been shown to be an important asset to weight loss and prevention of nutrient deficiencies (2). Since many patients suffer from poor nutrition before surgery, it is important to have a preoperative nutritional assessment and evaluation given by a dietitian, physician, or well-informed, qualified multidisciplinary team (19). This is an important first step to successfully prevent previously discussed nutrient deficiencies and to best prepare the patient and their family for upcoming dietary and lifestyle changes. During the initial dietary evaluation, the dietitian should reveal nutritional and behavioral risks preoperatively. In accordance with the multidisciplinary team, it is critical to develop a plan for postoperative nutritional intake and lifestyle changes (2).
The management of postoperative nutrition begins with preoperative nutrition. There are 3 strategies that must be considered: (a) assessment of nutrition, (b) comprehensive nutrition counseling with established goals, and (c) a follow-up plan to reinforce important principles associated with long-term weight loss maintenance (2). Nutrition assessments often consist of self-food logs, food frequency questionnaires, and eating behavior questionnaires to help determine what kind of diet the individual is consuming, how often food is consumed, the nutritional value of the diet, hydration status, proper vitamin/mineral intake, and family and/or caregiver support. It is important to gather this information before surgery to best determine what dietary alterations to make before surgery. Preoperative diets consist of high protein, liquids, and daily supplements to ensure that they are getting adequate levels of required vitamins and minerals. The second preoperative consideration is nutrition education with a registered dietitian who specializes in bariatric nutrition. It is suggested that a dietitian establish preoperative nutritional goals with the patient to help plan their postoperative weight loss and dietary goals (19). Dietary goals should include reductions in portion sizes; limited intake of foods high in sugar, fat, and simple carbohydrates; avoiding alcohol and binge eating while also staying active and hydrated; all activities that a trained fitness professional can provide support.
The treatment plan should also include regular follow-up visits. Such visits are important for nutritional monitoring which should ideally take place at 1 month, 3 months, 6 months, and 1 year postoperatively. Regardless of the time frame, regular follow-up visits will help the patient stay accountable and hopefully on track with their weight and exercise goals. An often overlooked but important benefit of a preoperative nutrition program includes the reduction of fat around the liver. In bariatric populations, an enlarged liver presents complications to the bariatric procedure due to its close proximity to the stomach (27). Other nutritional benefits of a preoperative nutrition program include increased supplementation to help correct possible preexisting nutrient deficiencies, faster recovery, surgical outcomes, quality of life, and tolerance to the surgical procedure. It is important that preoperative nutrition goals are set, reviewed, and followed successfully by a nutrition professional to ensure appropriate rate of weight loss and minimizing complications postoperatively.
POSTOPERATIVE NUTRITION FOR THE PATIENT UNDERGOING BARIATRIC SURGERY
Postoperative nutritional care is two-fold. First, adequate intake of both macronutrients and micronutrients are needed to promote necessary support for postoperative healing and preservation of lean body mass during the rapid weight loss phase. Second, the foods consumed postoperatively must be introduced in a fashion that minimizes food intolerance symptoms and reduces possible side effects such as acid reflux or dumping syndrome while maximizing weight loss and supporting weight loss maintenance (2). The dietary progression for RYGB, LAGB, and GS will vary depending on the status of the individual and is commonly completed in multiple phases. For example, most nutritional programs use clear liquid for the first three days (95%), full liquid for the first two weeks (94%), pureed foods (77%), and ground or soft foods for the first 1–3 months (67%), along with sugar, fat, and/or fiber restrictions (87%) (2). After three months and in a progressive fashion throughout the next 12 postoperative months, both the volume of food and energy intake will be titrated back into the diet to minimize many of the adverse outcomes mentioned above, to facilitate optimal healing and to promote healthy weight loss. Commonly, this progressive regimen consists of more frequent (5–6 meals) but smaller meals that focus on protein intake and daily supplement use to help eliminate gastrointestinal side effects.
As a point of emphasis, protein intake should be monitored regularly by the bariatric team to ensure protein goals are met (19). According to a 2013 document jointly published by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society of Metabolic and Bariatric Surgery, the minimum recommended protein intake for individuals undergoing bariatric surgery ranges from 60 to 90 g/day or 1.0–1.5 g/kg/day of ideal body weight (6,28). It is imperative to consume adequate amounts of protein postsurgery regardless of caloric intake to prevent the loss of lean body mass and maintain a positive nitrogen balance. This can become more challenging, particularly in the first six postoperative months where the prescribed caloric intake might be as low as 700–900 kcals per day after RYGB (6). Secondary to the substantial reduction in energy intake, the need for adequate protein becomes paramount to help sustain lean body mass. Daily monitoring of B12, folate, iron, and calcium supplementation is a key consideration; consequently, a comprehensive multivitamin/mineral formulation is commonly prescribed. Gastrointestinal side effects are minimized and, in many cases, eliminated when the client undergoing bariatric surgery is able to successfully increase the frequency of their eating with a focus on high-quality, nutrient-dense foods in conjunction with an effective supplementation regimen. By engaging in these eating habits, a number of positive outcomes occur including increased energy levels and metabolic rate, strengthened immune system, and reductions in hunger, inflammation, bloating, diarrhea, vomiting, and body fat along with improvements in cholesterol levels, blood pressure, and prevention of malabsorption.
PATIENT UNDERGOING BARIATRIC SURGERY SUPPORT AND EXERCISE CONSIDERATIONS
Notwithstanding, the outward goal of bariatric surgery is weight loss. To be successful, behavioral changes, including the adoption of an exercise program, must occur to adapt to this lifestyle change. To maintain the weight lost postoperatively, research has shown that patients undergoing bariatric surgery require professional and peer support groups and lifestyle behavioral changes (28). Weight loss intervention groups are often formed to help with motivation and consistency. A recent meta-analysis found that consistent exercise for patients undergoing bariatric surgery leads to a 4.2% lower BMI one year postoperatively (25). Support groups often share the same situations which can help with the emotional, mental, and psychological challenges that a client undergoing bariatric surgery may face. In this respect, it is important to ease into the adoption of an exercise program and choose low-impact activities such as swimming or cycling while also setting realistic and attainable goals each week to allow for appropriate healing and other physical progressions. Notably, exercise and nutrition professionals can play a key role in this process due to the regular interaction that they will have with the patient. These professionals are encouraged to highlight small (and large) achievements that were made along the way and reward such achievements.
The two most important behavior changes include adherence to prescribed nutrition programs and incorporating a comprehensive exercise program that is supervised by a certified fitness professional with experience in the bariatric population. Adopting an exercise program after bariatric surgery is imperative and is considered to be one of the most important factors to help someone achieve long-standing, successful weight loss (4). Exercise in bariatric populations has been shown to increase fat loss, reduce lean body mass losses, build strength, lower blood pressure, improve balance, reduce appetite, improve mood and self-esteem, reduce fatigue, enhance immune function, strengthen bones, and relieve stress (4).
An important consideration for the personal trainer or fitness professional is that many times, clients undergoing bariatric surgery have little to no background with exercise which makes it difficult for them to begin an exercise program or to understand how to properly complete a workout regimen. Clinicians play a key role in encouraging a regular physical activity program. A recent study concluded that participation in a medically guided supervised weight management program that included monthly behavior modification visits for 6 months had a positive effect on physical activity postoperatively (31).
From an exercise prescription perspective, the focus should be on providing a balanced exercise program consisting of aerobic, resistance, and flexibility training preoperatively and postoperatively. Studies have shown that the majority of preoperative patients undergoing bariatric surgery are very sedentary and, most importantly, fail to make large increases in their physical activity postoperatively despite substantial weight loss (7). Preoperatively, The American Society for Metabolic and Bariatric Surgery generally recommends mild exercise (40–60% heart rate reserve) 20 minutes per session for 3–4 sessions per week before surgery to improve cardiorespiratory fitness, reduce risk of surgical complications, facilitate healing, and enhance postoperative recovery (4). For similar reasons, the American Heart Association recommends a preoperative exercise regimen of low-to-moderate intensity physical activity at least 20 minutes per session, 3–4 sessions per week (33). Postoperatively, exercise is recommended on most days of the week with durations of 30–60 minutes, initially hitting a minimum of 150 minutes per week of moderate-intense activity (50–70% V̇o2 reserve or heart rate reserve) for obese and overweight individuals; however, a recommended exercise dosage of 200–300 minutes per week is advised for further health improvement and promotion of long-term weight loss (14). Initially, aerobic training should be the major exercise mode because it provides the greatest health benefits with regard to improving heart function, preventing cardiovascular disease, weight loss, and endurance (43), with walking being a primary exercise mode consideration (4). As progression continues, other modes of exercise can include running, cycling, swimming, rowing, etc. Data by Wilms et al (42) in 2013 clearly indicates that bariatric surgery instigates significant weight loss and improvements in BMI while also enhancing overall tolerance for higher exercise intensities, a key point for the fitness professional who seeks to use exercise postoperatively. An excellent review for the interested reader on exercise considerations before and after bariatric surgery was published by Pouwels (34).
Resistance training is growing in popularity for many clinical populations and has the potential to improve strength and endurance in the bariatric population (1). In general, a sound resistance training program exerts a powerful anabolic stimulus to the involved musculature and can work effectively to help maintain muscle mass, particularly in the face of a dietary regimen that is likely restrictive in energy, protein, vitamins, and minerals (29). Moreover, resistance training is well documented to favorably improve body composition by promoting an increase in fat-free mass and decreases in fat mass while also mitigating any potential losses of bone mass (also due to a compromised dietary scenario) (1,29). Owing to the inherent external loads and documented changes in intrathoracic and intraabdominal pressures, resistance training should not be used before physician clearance and, preferably, is commenced with the help of an experienced fitness professional who can assist with proper breathing and technique.
Regardless, Huck et al (22) did report favorable outcomes for the incorporation of resistance training into a postoperative bariatric program. Owing to the body size of patients undergoing bariatric surgery and the likelihood of their physical size not being compatible with many exercise machines, free weights are a recommended consideration. All movements should replicate many daily tasks, and exercises that will compromise safety and body stability should be avoided until more weight is lost and strength is gained. Although specific exercise prescriptions are not available for patients undergoing bariatric surgery, previous work by Donnelly (14) and Pouwells (34) are available to provide general recommendations (Table). In this respect, a resistance exercise prescription of 1–2 sets of a 10–12 repetition maximum (RM) or 65–70% 1RM load would be an excellent starting point (14,34). After 3–4 weeks, an additional set of exercise can be added for each exercise. All major muscle groups (quadriceps, gluteals, hamstrings, chest, back, shoulders, biceps, triceps, gastrocnemius/soleus complex, abdominals, and back extensors) should be targeted for at least 1–2 exercises. An exercise frequency of 2–3 days per week with 48 hours of rest between sessions is recommended. Rest periods of 1–2 minutes between each exercise set is advisable (14,34). Finally, fitness professionals should help set realistic short-term, process-based goals to help with the achievement of long-term goals. Flexibility training is also a popular and beneficial consideration for its ability to improve range of motion, coordination, intramuscular blood flow, and chronic musculoskeletal problems such as lower back pain (14). As with nearly all clinical populations, medical clearance postsurgery is needed before beginning any form of an exercise program to ensure safe completion of the prescribed exercise program.
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Table: General exercise recommendations for individuals after bariatric surgery
CONCLUSION AND FINAL RECOMMENDATIONS
Bariatric surgery is a surgical approach specifically intended for weight loss. Secondary to the surgically induced changes, a number of nutritional and dietary challenges arise in a large percentage of patients undergoing bariatric surgery after completion of the surgical procedure that must be addressed and managed by a licensed dietitian. It is important for fitness professionals to understand and be aware of the likelihood of gastric distress, macronutrient, and micronutrient deficiencies. All such conditions can negatively impact the energy levels of a client undergoing bariatric surgery, and their adherence and motivation to exercise.
Weight loss success from this approach depends on other lifestyle changes such as daily supplement use, proper nutrition, daily exercise, and lifestyle and behavior modification. Such lifestyle changes are imperative to help make bariatric surgery a successful weight loss tool. For this reason, bariatric surgery is not applicable for everyone who is obese or overweight but rather for only those who are committed to making long-term changes and continuing long-term lifestyle modification. Consequently, not all potential candidates of weight loss surgery are deemed as good candidates. Allied health professionals such as dietitians, exercise physiologists, and certified personal trainers are needed as a part of the long-term care team. Careful consideration must be made when assessing, educating, and monitoring individuals undergoing bariatric surgery for long-term success. Collectively, the bariatric team of professionals often plays a critical role in helping patients become successful in their weight loss goal, maintenance, and lifelong journey to live a healthier longer life.
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